Individual
LARRY D JACKSON
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
PA-C
Contact information
Practice address
500 GYPSY LN, YOUNGSTOWN, OH 44504-1315
(330) 884-1000
Mailing address
16620 DOWNEY GLEN TRL, BURTON, OH 44021-9319
Taxonomy
Speciality
Code
Description
License number
State
146D00000X
Personal Emergency Response Attendant
50000351
OH
363A00000X
Physician Assistant
Primary
50-000351
OH
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
970029949
MEDICARE TRAVELERS RR-GA
OH
Enumeration date
07/21/2006
Last updated
11/20/2014
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